Media Release Form for Incoming Students

Maryville College Media Consent Form

First Name

Last Name

Are you currently under the age of 18?

Yes

Birthdate

Email Address

If you're under 18, please have your parent or legal guardian fill out the following:

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to student

I hereby grant, convey, release, and assign any and all rights to the photographic images made of my myself, as taken by agents of Maryville College and the media; and I hereby authorize the reproduction, exhibition, broadcast, copyright, and/or distribution of said images for promotional purposes without limitation. I hereby release and hold harmless Maryville College, its agents, representatives, employees or any person or persons acting under its permission and/or authority. I certify that I am over 18 years old.

As the parent or legal guardian for this student, I hereby grant, convey, release, and assign any and all rights to the photographic images made of my child or legal ward, as taken by agents of Maryville College and the media; and I hereby authorize the reproduction, exhibition, broadcast, copyright, and/or distribution of said images for promotional purposes without limitation. I hereby release and hold harmless Maryville College, its agents, representatives, employees or any person or persons acting under its permission and/or authority. I certify that I am over 18 years old.

By signing this Electronic/Digital Signature form, I agree that my electronic/digital signature is the legally binding equivalent to my handwritten signature and has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic/digital signature or claim that my electronic/digital signature is not legally binding.

I ACKNOWLEDGE AND ACCEPT

Student Signature (Type Full Name)

Parent/Guardian Signature (Type Full Name)

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Media Release Form for Incoming Students

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